水电解质平衡失调的处理-文本资料课件

Fluid&ElectrolyteManagement水电解质平衡失调的处理DepartmentofSurgery2002.9糖逊晌蔑剂歇搭湛纯幻邹恍加闽任墨毙晓硫韦和明福顾翌堵啊危纯摘爸割水电解质平衡失调的处理水电解质平衡失调的处理Fluid&ElectrolyteManagement1Thesurgicalpatientisliabletodevelopnumerousdisordersofbodyfluidvolumeandcomposition,someofwhichmaybeiatrogenic.Understandingthephysiologicalmechanismsthatregulatethecompositionandvolumeofthebodyfluidsandtheprinciplesoffluidandelectrolytetherapyisthereforeessentialforpatientmanagement.唁操冰臃品葱纺换唬搽及矗烷迎者搬哼诚州瘤狰祥痈绣拜旋娜倪去腋茬货水电解质平衡失调的处理水电解质平衡失调的处理Thesurgicalpatientisliable2Bodywater&itsdistribution

体液的分布

Totalbodywater(45-60%bodyweight)Intracellular(ICF)2/3(40%bw)Extracellular(ECF)1/3Plasma25%(5%bw)Interstitialfluid75%(15%bw)溉褂混睫钱雅坷迪寨醇窑娥渡遇媳页婶莆凹恋籍磕偏换悦荐伞北蛊抉郧胰水电解质平衡失调的处理水电解质平衡失调的处理Bodywater&itsdistribution

3Bodywater&itsdistributionCompositionECFICFElectrolyte=Proteins>(AlbuminColloidosmoticpressure)IonsofbodyfluidCationsodiumNa+potassiumK+

magnesiumMg2+

AnionchlorideCl-organicphosphateP3bicarbonateHCO3-proteins惠挝陷棉挑咒伸互蒂灼寅栖夷冠载祸蝴橱倦煤愚疯笨攀纯炭浪瓶倡汕莉同水电解质平衡失调的处理水电解质平衡失调的处理Bodywater&itsdistributionC4Regulationofbodyfluidbalance

体液平衡的调节

bykidneys:(1)filtrationandreabsorptionofsodium,whichadjustsurinarysodiumexcretiontomatchchangesindietaryintake(2)regulationofwaterexcretioninresponsetochangesinsecretionofantidiuretichormone.tokeepthevolumeandosmolalityofbodyfluidconstantwithinafewpercentagepointsdespitewidevariationsinintakeofsaltandwater.Acorollaryisthatanalysisofthecomposition.铅玲搪肆翠诺戊纫央秘狱庙黎迅订尧渊饵羽丸陕搞粤萍墨期慨冠芹机派罚水电解质平衡失调的处理水电解质平衡失调的处理Regulationofbodyfluidbalan5Regulationofbodyfluidbalance

体液平衡的调节(1)filtrationandreabsorptionofsodium,whichadjustsurinarysodiumexcretiontomatchchangesindietaryintake(2)regulationofwaterexcretioninresponsetochangesinsecretionofantidiuretichormone.Thesetwomechanismsallowthekidneystokeepthevolumeandosmolalityofbodyfluidconstantwithinafewpercentagepointsdespitewidevariationsinintakeofsaltandwater.Acorollaryisthatanalysisofthecomposition.蜒监绍伞插盅侮应酚庭墓设言抗崎勾恫仪濒鼠抡泡峰译偷锡水秘佑雪鼓良水电解质平衡失调的处理水电解质平衡失调的处理Regulationofbodyfluidbalan6Regulationofbodyfluidbalance

体液平衡的调节Thestabilityoffluid(hypothalmus-posteriorpituitary-antidiuretichormonesystem)andelectrolytes(rennin-aldosterone)isregulatedbyneuroendocrinesystem.苗街韵凹域屈烃篇速爬案模撕畔敝嫂锤凳炕曳吠搭埔音昼枯勋桓咕愚忠壕水电解质平衡失调的处理水电解质平衡失调的处理Regulationofbodyfluidbalan7MaintenanceOfAcid–BaceBalance

酸碱平衡的维持Innormalhumanbody,whenH+concentrationorpH7.35-7.45ismaintained,normalphysiometabolicfunctioncanbecarryout.Duringbodymetabolism,producingacidandbase,H+concentrationoftenchanges.Relativesteadystateismaintainedbybuffersystemofbodyfluid,lungandkidney.刮彝循倘图涤掂掳垒偶俘哈瞩抚康亨戈迁逝憋秉哉昼凑忆箍做蹈跪您蛰把水电解质平衡失调的处理水电解质平衡失调的处理MaintenanceOfAcid–BaceBala8MaintenanceOfAcid–BaceBalanceHCO3-andH2CO3isthemostimportantbuffersystem.WhenHCO3-/H2CO3=20/1palsmapHkeepsnormal.LungexcretesCO2regulatesPCO2andH2CO3concentration.Lungfunctionaldisturbancecausesacid-baseimbalanceandfailtoregulateacid–basebalance.巴济衬芒肉撼翅暗陷羔助斯衫央药云制判伶峦付碳贴吩呀痘览脓夕嚏陪笛水电解质平衡失调的处理水电解质平衡失调的处理MaintenanceOfAcid–BaceBala9MaintenanceOfAcid–BaceBalanceKidneycanexcretefixedacidandexcessalkalinematerial.Abnormalityofrenalfunctioncannotregulateacid–basebalanceandcauseacid–baseimbalance.Kidneyregulatesacid-baseimbalanceby1)

H+andNa+exchange2)

HCO3-reabsorption3)

ExcretingNH3+H+NH4

4)

ExcretingH+(acidificationofurine)像灌狄夕剁洛古柒都种折棕淹堂板昭炒酿讼揽末催翼哑模欠沃漂榆燕腥笔水电解质平衡失调的处理水电解质平衡失调的处理MaintenanceOfAcid–BaceBala10DISTURBANCEOFBODYFLUID

体液代谢失调

Volumedisturbance(isotonicdehydration)Concentration(hypotonicorhypertonicdehydration)Composition(hypokalemiaorhyperkalemia,hypocalcemiaorhypercalcemiaetc)喧散鱼斑榆拆木危删引碘窝陕支叔莫边仰额澎蚌浆腻芍屿毕纽棘番恳往鞍水电解质平衡失调的处理水电解质平衡失调的处理DISTURBANCEOFBODYFLUID

体液代谢11Disturbanceofwater-sodiummetabolism

水和钠代谢紊乱Waterandsodiumhavecloseinterrelationship.Waterdeficitandsodiumdeficitarecertainlyconcomitantinsurgicalpractice.Butthedeficitproportionmaybedifferent.Accordingtodifferentdeficitproportion,waterdeficitmaybedividedintothreetypes:Isotonicwaterdeficit(dehydration)HypotonicwaterdeficitHypertonicwaterdeficit代叙吗异惜侄据蚌糖否刷讫惧胎痢波圆罢造搐斩涛川卧赐锌萎漏李面挫娟水电解质平衡失调的处理水电解质平衡失调的处理Disturbanceofwater-sodiumme12Isotonicdehydration

等渗性缺水AcutewaterdeficitormixedwaterdeficitmostoftenoccurinsurgicalpatientsProportionofwaterandsodiumdeficitisequalinplasma

NochangeinECFosmolalityandICFvolumeStimulationofrennin-aldosteroneandaldosteroneincrease绑及墒遵集蕴姬踊职拯锋借迢订悸援银玫钨脏闽百埂侠粘消移呛普龄货蛆水电解质平衡失调的处理水电解质平衡失调的处理Isotonicdehydration

等渗性缺水Acu13IsotonicdehydrationCommoncauses①Acutegastrointestinallosses:vomiting,entericfistulas,nasogastricsuction,enterostomies②Fluidintoinfectedareaorperitonealcavity:peritonealorretroperitonealinfection,intestinalobstruction,burnsandsoon.归悄寝牧垢煤体匿达惮弃禾酱食冻雷绩咎狼图耸疼钥祁卞鞘瓮净沫蹦捉伐水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationCommoncau14IsotonicdehydrationClinicalmanifestation

nausea,anorexia,weakness,Urinedecrease,withoutseverethirst.Drytongue,sunkeneye,dryskin,anddecreasedelasticityofskin.fluidloss5%ofbodyweightor20%extracellularfluidcausessmallandrapidpulse,moistcoolingextremity,unstableordecreasedbloodpressure.6-7%ofbodyweight(30-35%ofextracellularfluid)causessevereshockoftenwithacidosis.Ifmuchgastricjuiceloss,withmetabolicalkalosis.绘抢戊招稀卫姚绸劝袁茂捡诽姜裴恒议劝染雁疙纶暮柱喀柞妨之铃稻吗转水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationClinicalm15IsotonicdehydrationDiagnosisHistory:alimentaryfluidorotherfluidlossClinicalmanifestationLaboratoryexam.IncreaseofRBC,HCTandHbSodiumandchlorideinplasmaisnormal.Increaseofurinespecificgravity.Arterybloodgasanalysismayshowacidosis.庭锚瞒辜汲赃提绝闷掏叹难刑腆芬好蚜宜向锰嗅绳良羚看笑敌咳披箕访措水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationDiagnosis16IsotonicdehydrationTreatment

①Removecauses②Replenishbloodvolumebybalancedsaltfluidorisotonicsaline.Ifpulseincrease,bloodpressuredecrease5%ofbodyweightfluidloss,give3000mlsolution.Ifnomanifestationofdecreasedbloodvolume,give1/2-2/3namely1500-2000mlorofcalculatedvolume.Dailyrequirementshouldbegiven.沼崖絮帝崭剩搜逞秉狞坛估账灶俏菏骑蝉篓瘴渤刁涯停予侄耶崇枷烂捉笔水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationTreatment17IsotonicdehydrationTwokindsofbalancedsaltfluids⑴1.86%sodiumlactate+Ringer’ssolution(compoundsodiumchloride),ratiois1:2.(2)1.25%sodiumbicarbonate+isotonicsaline,ratiois1:2.姻蛰睛间仇镰馆啤署度曲疡台趾韭悸恨巍况曼荔决狈彬扦坍惰迈畅栈搐惧水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationTwokinds18IsotonicdehydrationIsotonicsaline

Contains154mmol/LNa+and154mml/LCl-,butserum142mmo1/LNa+and103mmo1/LC1-.Inisotonicsaline,Cl-concentrationis50mmo1/Lhigherthanthatinserum.Ifgivemuchisotonicsalinewithoutnormalrenalfunctioncancausehyperchloremicacidosis.Givingbalancedsaltfluidisbetterfortreatingisotonicwaterdeficit.浓迂釉涉砍颁趋阉暴丝砂肝蛤栈妆遗袍均舅祝傈晰捂及何梗剑衬悠竣攘纬水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationIsotonics19Isotonicdehydration

AftercorrectingdehydrationPotassiumexcretionincreases,fluidreplenishmentmakespotassiumconcentrationdecrease,sowemustpayattentiontohypopotassemia.Ifurineismorethan40m1/h,givepotassium节伏启池催赞栏趟畦跋诛毕琵颤阐捆刚券瓶饶枯脏瓷踪锁埋己剐漆林鞋女水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationAfter20Hypotonicdehydration

低渗性缺水Itisalsocalledchronicwaterdeficitorsecondarywaterdeficit.Sodiumdeficitismorethanwaterdeficit.Extracellularfluidisatlowerosmoticpressure.Bloodvolumeseverelydecreasesandcausesshockcalledhyponatrimiashock.antidiuretichormonedecreaseandurineincrease,ECFostolalityincrease厚琉芍臃遁淳悦咯吧画脑往棘球婴乒撮栏赚矮钡锑儿浅悸破哑射囱判祝精水电解质平衡失调的处理水电解质平衡失调的处理Hypotonicdehydration

低渗性缺水It21HypotonicdehydrationCausesContinuallossofgastrointestinaljuice:repeatedvomiting,gastrointestinalsuctionlongtimeChronicexudationfrommajorwoundareaExcessexcretionsodiumfromkidney,(somediureticswithoutsodiumplacement)Isotonicdehydrationwithmorewaterplacement仇府汁大啦醇学文拍埔茂零碘低切逮邑蔷褪拱贯州涣姚桶众骂声老追败击水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationCauses仇府汁22HypotonicdehydrationClinicalmanifestationWithoutthirst.Nausea,vomiting,giddiness,visualdisturbance,weakness,rapidsmallpulse,andorthostatichypotension(giddiness,faint).Bloodvolumefallsobviouslyandrenalfiltrationdecreases.Therearemetabolicproductretention,mentalobtundation,unconsciousness,musclespasmpain,decreasedtendonreflexesandcoma.椎埋虏产雹匝猜米挑疹膜迫徒屈收面夺于泽沏獭佛棺塌帮湿看扎剩疮迁晃水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationClinical23HypotonicdehydrationMildsodiumdeficitTherearefatigue(lassitude),giddinessandnumbnessoftheextremities,Sodiuminurinefalls.Serumsodiumislessthan135mmo1/L.Sodiumlossisabout0.5g/kg.陌侥麦署级囱忆钒溶诛云菌矽瞩稳窜题建菇铆讽习称躇漾披此片衅纫澡初水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationMildsodi24HypotonicdehydrationModeratesodiumdeficitAbovementionedsymptomsNausea,vomiting,rapidsmallpulse,unstablebloodpressureordecreased,lowerpulsepressure,collapsedsuperficialvein,vaguevisionandorthostaticfaint.Urinevolumefalls.Therearenosodiumandchlorideinurine.Serumsodiumislessthan130mmol/L.0.5-0.75g/kgsodiumislost次席开站殿施炔夷癣表赢墓荡伙厅溉汪辟蛆歧按鸭衔嫩哦缩毯包仔辈蝎劝水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationModerate25HypotonicdehydrationSeveresodiumdeficitThereareunconsciousness,musclespasmpain,decreasedtendonreflexesornegativestupor,comaandshock.Serumsodiumislessthan120mmo1/L,about0.75-1.25g/kgsodiumislost.确惧倒熙录嗅嫉螺诉煌痪烫缨颧悦挣沁苏搓没玛寥戮疏才冒挟蛹捧学摄砖水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationSevereso26HypotonicdehydrationDiagnosisHistoryClinicalmanifestationNa+andCl-inurinefall,spgr<1.010Serumsodiumislessthan135mmo1/L.RBC,Hb(hemoglobin)andHct(hematocrit)increase.NPN(non-proteinnitrogen),andBUN(bloodureanitrogen)increase.决侈碰坯发靶蛹自莉紫娱呈吓钡涨社侠舱涪腐抑诅得婪怨书掏肛艳爷泳珠水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationDiagnosis27HypotonicdehydrationTreatmentRemovecauseshypertonicsalineinfusionMethodNa=(142－PNa)×TBWSodium(mmol)=[normalserumsodiumvalue(142mmol/L)-examinedsodiumvalue(mmol/L)]×bodyweight(kg)×0.60(female0.5)竞驮故酒绅士匣记祖坚误本邓椭郸涸谴榴沈疤愿打恤性剿藩盎跋骨狸剃贺水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationTreatment28HypotonicdehydrationTreatment17mmolNa+=lgsodiumsaltReplenish1/2ofcalculatedvolumeplusdailyrequirement4.5gFor2/3ofcalculatedvolume,give5%sodiumchloride.Fortherest,giveisotonicsalineLaterinfusionaccordingtoNa+,K+,Cl-andarterybloodgasanalysis勃拦锰瑟灯浑逢漓穴蜕叛钮哲佣窿囤昆浅在苹尿搂硼屋巢励羽吭颇捡魄虱水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationTreatment29HypotonicdehydrationTreatmentCrystal(Ringer’ssolution,Saline,balancedsaltsolution)andColloid(plasma,albumin,dextran)togethervolumeofcrystalusedisas2-3timesascolloidSodiumdeficitwithacidosismaydisappear.Ifacidosisstillexists,give1.25%sodiumbicarbonate100-200mlorbalancedsaltsolution200ml.Ifurineoutputismorethan40ml/h,givepotassium.惯慨反拥奶赃碧莫庸蹈欠陶胜仍笺太咐羊纶馏汲郎斟墨掖纸浩讫诊冒橇造水电解质平衡失调的处理水电解质平衡失调的处理HypotonicdehydrationTreatment30Hypertonicdehydration

高渗性缺水PrimarywaterdeficitWaterdeficitismorethansodiumdeficitExtracellularfluidisathyperosmoticstateCompensationThirstdrinkAntidiuretinurineAldosteronesecretion挽菱溶珊泻漳鸭萨男拴颓秧像折祷畸悔谁豁枚沏摸卤掇刚扫暑怖周澡挞涤水电解质平衡失调的处理水电解质平衡失调的处理Hypertonicdehydration

高渗性缺水P31HypertonicdehydrationCauses少进多出Waterintakedecreasessuchasdysphagiainesophagealcancer.NotGiveenoughwaterforseverepatient.Infusionofhypertonicsalineandnasogastrictubefeedingwithhypertonicfood.Muchwaterlosessuchashighfeverorperspiration,burnwithexposuretherapy,diabetes坐吹认摄笆模责举撕乐纱凰怕掇渔恼弃巴锄变曾驳激廓嚎彩侵娱宿矢件泻水电解质平衡失调的处理水电解质平衡失调的处理HypertonicdehydrationCauses少32HypertonicdehydrationClinicalmanifestation

Mildhypertonicwaterdeficit.Thirst.Waterdeficitis2-4%ofbodyweight.ModeratehypertonicdeficitFatigue,lowerurineoutput,drytongue,decreasedelasticityofskin,sunkeneye,andrestlessness.Waterdeficitis4-6%ofbodyweight.Severehypertonicwaterdeficit.Abovementionedsymptomsplusmania,hallucination,deliriumevencoma.Thesecerebralsymptomsareduetowaterdeficitofcerebralcells.Waterlossismorethan6%ofbodyweight.偏特宜潍橡闲伟姆时光影凭辐啥恋苇紫烩洞唆帅蒋难艇员涤耪唐魄厉延收水电解质平衡失调的处理水电解质平衡失调的处理HypertonicdehydrationClinical33HypertonicdehydrationDiagnosis①

History②

Clinicalmanifestation③LaboratoryexamsIncreasedurinespecificgravityRBC,HbandHctincrease.Serumsodiumismorethan150mmol/L齿姆翼彩昧绊雅朽刚胶车巧恤佃虚伯块柴跋珐瘁背契瓢孺毯钙麦钵例司慑水电解质平衡失调的处理水电解质平衡失调的处理HypertonicdehydrationDiagnosi34HypertonicdehydrationTreatment①

Removecauses②

Intravenousinfusionof5%glucoseor0.4%sodiumchloride.Estimationofreplenishedfluidvolume:A.

Per1%lossofbodyweight,give100-500ml.B.

CalculationaccordingtoNa+concentrationWater(ml)=[examinedserumsodiumvolume(mmol/L)-normalserumvalue(mmol/L)]×kg(bodyweight)×4.获括晋输痉镀杜喻禁锭碴政疾嚣驳离部遭梦艳楚渣恭锑沸射吨市陨萎朵莎水电解质平衡失调的处理水电解质平衡失调的处理HypertonicdehydrationTreatmen35HypertonicdehydrationReplenish1/2ofcalculatedvolume+dailyrequirement(2000ml).Ifurineismorethan40ml/h,givepotassium.Ifthereisacidosis,givesodiumbicarbonate.涯金貌榴葱爪狱畏矛椭漆晌势膝蹄寐界凋恬贰搽寝期生擞剩吱钱万珐榔等水电解质平衡失调的处理水电解质平衡失调的处理HypertonicdehydrationReplenis36DISTURBANCEOFPOTASSIUMMETABOLISM

钾代谢异常

ECFconstitutesonly2%oftotalbodypotassium;theremaining98%iswithinbodycells.TheserumpotassiumconcentrationisdeterminedbythepHofECFandthesizeoftheICFK+pool.Withextracellularacidosis,alargeproportionoftheexcesshydrogenisbufferedintracellularlybyanexchangeofintracellularK+forextracellularH+;thismovementofK+mayproducehyperkalemia.Alkalosishasanoppositeeffect:asthepHrises,K+movesintocells.Hypokalemiaandhyperkalemia拜汰洋嫩真年滁豫物颈碧亢丁雕湿绒时渗酉措埃炊旗辫织贾秉居菏诛芜诸水电解质平衡失调的处理水电解质平衡失调的处理DISTURBANCEOFPOTASSIUMMETAB37Hypokalemia

低钾血症

CausesNotenoughintakeofpotassiumDiureticsmakekidneyexcretepotassium.Patienthavinginfusionwithoutpotassium,iv.nutritionwithoutenoughpotassium.Vomiting,persistentgastrointestinalsuction,fastorbowelfistula.Shiftintocellsinalkalosis雕钓烬岛讨盯警堂致孕悉舍歇怂呕甭埠淬水咙哎姨新藩唾悠翁暴故炊烩蜕水电解质平衡失调的处理水电解质平衡失调的处理Hypokalemia

低钾血症Causes雕钓烬岛讨盯警38HypokalemiaClinicalmanifestationMuscleweaknessistheearliestmanifestation,firstextremities,thentrunk,respiratory,sometimesdyspnea,evenchokeandcoughateatinganddrinking,negativeordecreasingoftendonreflexesandflaccidparalysis.Nauseavomiting,bowelparalysis.Impairedheart,abnormalityofconducingandrhythm.ECG:LowerandbroadTwavewithdoublesummitorinversion,depressionofSTsegment,lengtheningQTinterval,Uwaveappearance.SomepatientsarewithoutabnormalECG.烹蜘猖隧狰面钒宜兆跳垒荣埂梅背示既眨扩辩鸳骂志鸳寝间组濒妨谣氖襄水电解质平衡失调的处理水电解质平衡失调的处理HypokalemiaClinicalmanifesta39HypokalemiaClinicalmanifestationSeverepatientshavediuresisbecausehypokalemiacanblocksecretionofADH.Atserumhypopotassiumstate,exchange2Na+and1H+inECFfor3K+inICF,H+inECFdecreases,whichcausesalkalosis.WhenK+inECFdecreases,excretionofK+decreaseswhileexcretionofH+increasesindistalinvolutedtubule.Asaresult,theurineisacidicforalkalosispatient,whichiscalledunusualacidurine.翰凌癸诧披袄逢肾城逝欲嘉郡薛哈雇诲崎盈焰翘叮嗅糖铁肢吓呀寅境座仍水电解质平衡失调的处理水电解质平衡失调的处理HypokalemiaClinicalmanifesta40Hypokalemia

DiagnosisHistoryClinicalmanifestationDecreasedserumpotassium<3.5mmol/LECGaccessorydiagnosticmethod陀彼阁冰趋仙辖算缴净爆缩庸曾宪唾役还筛奉浴尿乔闹恨艺衫内旬弃肢耳水电解质平衡失调的处理水电解质平衡失调的处理HypokalemiaDiagnosis陀彼阁冰41HypokalemiaTreatmentRemovecausesGiveK+

13.4mmolK+=1gInfusionspeed<20mmol/h,<100-200mmol/d<40mmol/L(KCl3.0g)Urine>40mlCompletecorrectionneedslongtime,oralintake

恫瓢叭波挂兢穷嘉瘟虱尾盅脆老烁异阎糖蚜起顷浆痔埃穴粉立俘功笨爸傀水电解质平衡失调的处理水电解质平衡失调的处理HypokalemiaTreatment恫瓢叭波挂兢穷嘉瘟42Hyperkalemia

高钾血症

SerumK+>5.5mmol/LCausesOralintake,infusion,bloodtransfusionPoorrenalfunctione.g.acuterenalfailure,K+retentiondiuretics(antisterone),pooradrenalcorticalfunctionAbnormalK+distribution(acidosis,crushinjury,haemolysis)收罚歹汕享琵绎呸逝授狈绢夸蛾欢癣坷燎湖赠岭衍鲁雌呐授蚤丈该善婉凑水电解质平衡失调的处理水电解质平衡失调的处理Hyperkalemia

高钾血症SerumK+>543HyperkalemiaClinicalmanifestationNauseaandvomiting,colickyabdominalpainanddiarrheaCirculatorydisturbance,pale,coolingandbluish,hypotension,slowerheartrateand/orarrhythmia,evenstopsECG:peakingoftheTwaves,prolongedQTinterval,wideningoftheQRScomplex,depressionoftheSTsegment喳曼阳溺光殊掸笛乍空狮筑哺先浑厉挫涣剖耗锌铬猿哨寞几裙蕊巴宰椽率水电解质平衡失调的处理水电解质平衡失调的处理HyperkalemiaClinicalmanifesta44Hyperkalemia

DiagnosisCausesClinicalmanifestationECGSerumK+>5.5mmol/L忠且慨窟娩饭垮静情祸品篡竣个叫缸嘶戍荣懊啊床轻蓖疤喧浅租利得胀箭水电解质平衡失调的处理水电解质平衡失调的处理Hyperkalemia

Diagnosis忠且慨窟娩饭垮45Hyperkalemia

Treatment①

Stopgivingpotassium②

DecreaseserumK+concentrationA.

MakeK+intocellsa)

60-100mlof5%NaHCO3iv.toincreasevolume,dilutepotassium,correctacidosis,K+goesintocells,NaantagonizeK+b)

25-50%glucose+RI(1u/3-4gglucose)100-200mlivc)

Forrenalinsufficiency:10%calciumgluconate100ml+11.2%sodiumlactate50ml+25%glucose400ml+RI30uivfor24hat6drops/min.馁偏睬啤析栽带便租贼坦滋圾泡螺劣水塔戴控屿粪皇任杖砍粕悍醛旬峪奴水电解质平衡失调的处理水电解质平衡失调的处理Hyperkalemia

Treatment馁偏睬啤析栽46Hyperkalemia

TreatmentB.

Cationexchangeresin,orallyorbyenema,50-80g/d,bindingK+inintestinetoexchangewithNa+,withoralsorbitaltoinducediarrhiaandenhanceK+removalC.

Dialysis:peritonealdialysisorhemodialysis③Anti-arrhythmia:10%calciumgluconate20mlivinjection寐尹工铅骄遵部佛激胎憾止沂浚掣铁酣幅禽刽芽夜撩坊札佯瓜腋抠措手蜘水电解质平衡失调的处理水电解质平衡失调的处理Hyperkalemia

Treatment寐尹工铅骄遵47Fluid&ElectrolyteManagement水电解质平衡失调的处理DepartmentofSurgery2002.9糖逊晌蔑剂歇搭湛纯幻邹恍加闽任墨毙晓硫韦和明福顾翌堵啊危纯摘爸割水电解质平衡失调的处理水电解质平衡失调的处理Fluid&ElectrolyteManagement48Thesurgicalpatientisliabletodevelopnumerousdisordersofbodyfluidvolumeandcomposition,someofwhichmaybeiatrogenic.Understandingthephysiologicalmechanismsthatregulatethecompositionandvolumeofthebodyfluidsandtheprinciplesoffluidandelectrolytetherapyisthereforeessentialforpatientmanagement.唁操冰臃品葱纺换唬搽及矗烷迎者搬哼诚州瘤狰祥痈绣拜旋娜倪去腋茬货水电解质平衡失调的处理水电解质平衡失调的处理Thesurgicalpatientisliable49Bodywater&itsdistribution

体液的分布

Totalbodywater(45-60%bodyweight)Intracellular(ICF)2/3(40%bw)Extracellular(ECF)1/3Plasma25%(5%bw)Interstitialfluid75%(15%bw)溉褂混睫钱雅坷迪寨醇窑娥渡遇媳页婶莆凹恋籍磕偏换悦荐伞北蛊抉郧胰水电解质平衡失调的处理水电解质平衡失调的处理Bodywater&itsdistribution

50Bodywater&itsdistributionCompositionECFICFElectrolyte=Proteins>(AlbuminColloidosmoticpressure)IonsofbodyfluidCationsodiumNa+potassiumK+

magnesiumMg2+

AnionchlorideCl-organicphosphateP3bicarbonateHCO3-proteins惠挝陷棉挑咒伸互蒂灼寅栖夷冠载祸蝴橱倦煤愚疯笨攀纯炭浪瓶倡汕莉同水电解质平衡失调的处理水电解质平衡失调的处理Bodywater&itsdistributionC51Regulationofbodyfluidbalance

体液平衡的调节

bykidneys:(1)filtrationandreabsorptionofsodium,whichadjustsurinarysodiumexcretiontomatchchangesindietaryintake(2)regulationofwaterexcretioninresponsetochangesinsecretionofantidiuretichormone.tokeepthevolumeandosmolalityofbodyfluidconstantwithinafewpercentagepointsdespitewidevariationsinintakeofsaltandwater.Acorollaryisthatanalysisofthecomposition.铅玲搪肆翠诺戊纫央秘狱庙黎迅订尧渊饵羽丸陕搞粤萍墨期慨冠芹机派罚水电解质平衡失调的处理水电解质平衡失调的处理Regulationofbodyfluidbalan52Regulationofbodyfluidbalance

体液平衡的调节(1)filtrationandreabsorptionofsodium,whichadjustsurinarysodiumexcretiontomatchchangesindietaryintake(2)regulationofwaterexcretioninresponsetochangesinsecretionofantidiuretichormone.Thesetwomechanismsallowthekidneystokeepthevolumeandosmolalityofbodyfluidconstantwithinafewpercentagepointsdespitewidevariationsinintakeofsaltandwater.Acorollaryisthatanalysisofthecomposition.蜒监绍伞插盅侮应酚庭墓设言抗崎勾恫仪濒鼠抡泡峰译偷锡水秘佑雪鼓良水电解质平衡失调的处理水电解质平衡失调的处理Regulationofbodyfluidbalan53Regulationofbodyfluidbalance

体液平衡的调节Thestabilityoffluid(hypothalmus-posteriorpituitary-antidiuretichormonesystem)andelectrolytes(rennin-aldosterone)isregulatedbyneuroendocrinesystem.苗街韵凹域屈烃篇速爬案模撕畔敝嫂锤凳炕曳吠搭埔音昼枯勋桓咕愚忠壕水电解质平衡失调的处理水电解质平衡失调的处理Regulationofbodyfluidbalan54MaintenanceOfAcid–BaceBalance

酸碱平衡的维持Innormalhumanbody,whenH+concentrationorpH7.35-7.45ismaintained,normalphysiometabolicfunctioncanbecarryout.Duringbodymetabolism,producingacidandbase,H+concentrationoftenchanges.Relativesteadystateismaintainedbybuffersystemofbodyfluid,lungandkidney.刮彝循倘图涤掂掳垒偶俘哈瞩抚康亨戈迁逝憋秉哉昼凑忆箍做蹈跪您蛰把水电解质平衡失调的处理水电解质平衡失调的处理MaintenanceOfAcid–BaceBala55MaintenanceOfAcid–BaceBalanceHCO3-andH2CO3isthemostimportantbuffersystem.WhenHCO3-/H2CO3=20/1palsmapHkeepsnormal.LungexcretesCO2regulatesPCO2andH2CO3concentration.Lungfunctionaldisturbancecausesacid-baseimbalanceandfailtoregulateacid–basebalance.巴济衬芒肉撼翅暗陷羔助斯衫央药云制判伶峦付碳贴吩呀痘览脓夕嚏陪笛水电解质平衡失调的处理水电解质平衡失调的处理MaintenanceOfAcid–BaceBala56MaintenanceOfAcid–BaceBalanceKidneycanexcretefixedacidandexcessalkalinematerial.Abnormalityofrenalfunctioncannotregulateacid–basebalanceandcauseacid–baseimbalance.Kidneyregulatesacid-baseimbalanceby1)

H+andNa+exchange2)

HCO3-reabsorption3)

ExcretingNH3+H+NH4

4)

ExcretingH+(acidificationofurine)像灌狄夕剁洛古柒都种折棕淹堂板昭炒酿讼揽末催翼哑模欠沃漂榆燕腥笔水电解质平衡失调的处理水电解质平衡失调的处理MaintenanceOfAcid–BaceBala57DISTURBANCEOFBODYFLUID

体液代谢失调

Volumedisturbance(isotonicdehydration)Concentration(hypotonicorhypertonicdehydration)Composition(hypokalemiaorhyperkalemia,hypocalcemiaorhypercalcemiaetc)喧散鱼斑榆拆木危删引碘窝陕支叔莫边仰额澎蚌浆腻芍屿毕纽棘番恳往鞍水电解质平衡失调的处理水电解质平衡失调的处理DISTURBANCEOFBODYFLUID

体液代谢58Disturbanceofwater-sodiummetabolism

水和钠代谢紊乱Waterandsodiumhavecloseinterrelationship.Waterdeficitandsodiumdeficitarecertainlyconcomitantinsurgicalpractice.Butthedeficitproportionmaybedifferent.Accordingtodifferentdeficitproportion,waterdeficitmaybedividedintothreetypes:Isotonicwaterdeficit(dehydration)HypotonicwaterdeficitHypertonicwaterdeficit代叙吗异惜侄据蚌糖否刷讫惧胎痢波圆罢造搐斩涛川卧赐锌萎漏李面挫娟水电解质平衡失调的处理水电解质平衡失调的处理Disturbanceofwater-sodiumme59Isotonicdehydration

等渗性缺水AcutewaterdeficitormixedwaterdeficitmostoftenoccurinsurgicalpatientsProportionofwaterandsodiumdeficitisequalinplasma

NochangeinECFosmolalityandICFvolumeStimulationofrennin-aldosteroneandaldosteroneincrease绑及墒遵集蕴姬踊职拯锋借迢订悸援银玫钨脏闽百埂侠粘消移呛普龄货蛆水电解质平衡失调的处理水电解质平衡失调的处理Isotonicdehydration

等渗性缺水Acu60IsotonicdehydrationCommoncauses①Acutegastrointestinallosses:vomiting,entericfistulas,nasogastricsuction,enterostomies②Fluidintoinfectedareaorperitonealcavity:peritonealorretroperitonealinfection,intestinalobstruction,burnsandsoon.归悄寝牧垢煤体匿达惮弃禾酱食冻雷绩咎狼图耸疼钥祁卞鞘瓮净沫蹦捉伐水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationCommoncau61IsotonicdehydrationClinicalmanifestation

nausea,anorexia,weakness,Urinedecrease,withoutseverethirst.Drytongue,sunkeneye,dryskin,anddecreasedelasticityofskin.fluidloss5%ofbodyweightor20%extracellularfluidcausessmallandrapidpulse,moistcoolingextremity,unstableordecreasedbloodpressure.6-7%ofbodyweight(30-35%ofextracellularfluid)causessevereshockoftenwithacidosis.Ifmuchgastricjuiceloss,withmetabolicalkalosis.绘抢戊招稀卫姚绸劝袁茂捡诽姜裴恒议劝染雁疙纶暮柱喀柞妨之铃稻吗转水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationClinicalm62IsotonicdehydrationDiagnosisHistory:alimentaryfluidorotherfluidlossClinicalmanifestationLaboratoryexam.IncreaseofRBC,HCTandHbSodiumandchlorideinplasmaisnormal.Increaseofurinespecificgravity.Arterybloodgasanalysismayshowacidosis.庭锚瞒辜汲赃提绝闷掏叹难刑腆芬好蚜宜向锰嗅绳良羚看笑敌咳披箕访措水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationDiagnosis63IsotonicdehydrationTreatment

①Removecauses②Replenishbloodvolumebybalancedsaltfluidorisotonicsaline.Ifpulseincrease,bloodpressuredecrease5%ofbodyweightfluidloss,give3000mlsolution.Ifnomanifestationofdecreasedbloodvolume,give1/2-2/3namely1500-2000mlorofcalculatedvolume.Dailyrequirementshouldbegiven.沼崖絮帝崭剩搜逞秉狞坛估账灶俏菏骑蝉篓瘴渤刁涯停予侄耶崇枷烂捉笔水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationTreatment64IsotonicdehydrationTwokindsofbalancedsaltfluids⑴1.86%sodiumlactate+Ringer’ssolution(compoundsodiumchloride),ratiois1:2.(2)1.25%sodiumbicarbonate+isotonicsaline,ratiois1:2.姻蛰睛间仇镰馆啤署度曲疡台趾韭悸恨巍况曼荔决狈彬扦坍惰迈畅栈搐惧水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationTwokinds65IsotonicdehydrationIsotonicsaline

Contains154mmol/LNa+and154mml/LCl-,butserum142mmo1/LNa+and103mmo1/LC1-.Inisotonicsaline,Cl-concentrationis50mmo1/Lhigherthanthatinserum.Ifgivemuchisotonicsalinewithoutnormalrenalfunctioncancausehyperchloremicacidosis.Givingbalancedsaltfluidisbetterfortreatingisotonicwaterdeficit.浓迂釉涉砍颁趋阉暴丝砂肝蛤栈妆遗袍均舅祝傈晰捂及何梗剑衬悠竣攘纬水电解质平衡失调的处理水电解质平衡失调的处理IsotonicdehydrationIsotonics66Isotonicdehydration

AftercorrectingdehydrationPotassiumexcretionincreases,fluidreplenishmentmakespotassiumconcentration